0002-109 (SFD)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing mmencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class-) Exp: .Date
Date of
yContractor
OWNER -BUILDER DECLARATION
I hereby affirm unde I r penalty.of perjury that I am exempt from the A�Contractor's
License Law for the following reason: . !
( ) 1, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the- structure is not intended or offered for
sale (Sec. 7044, Business.& Professionals Code).
1, as owner. of the property, am' exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business' & Professionals
Code).
I am exempt under Section B&P.C.,for this reason
Date Signature of.,Owner
.WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provid6d for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is�igsued.
I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work, for which this
permit is issued. My workers', compensation insurance Carrier & policy no. are:
Cartier Policy No.
(This section need not be completed if the permit valuation is for,$100.00 or less).
O I certify that in the performance of the, work for which this �"permit is issued,
I shall not employ any person n in any manner so as to become subject to the
workers' compensation Jaws of California,,and agree that if I should become
subject to the workers' `compensation pr.8visions of Section 370' of the Labor
Code, I shlil forthwith comply with those, provisions
Date:L//_ Applicant- Z
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines Up to $100,000, in
addition to the cost of compensation, damages as provided for in -Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit Work is performed under or pursuant to
any
y permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers,* agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of 'such
permit, or cessation of work,fdr, 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply'with all 'City, and. State laws relating to the'building
construction, and hereby, authorize representatives. of, this City to enter upon
Date:' X
the above-mentioned property or�inspection pur oses."
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Signature (Owner/Ant) DazX"-)
�4!"
t .3,00 BUILDING PERMIT PERMIT#
f ,
DATE VALUATION LOTTRACT
'10
JOB SITEAPN
ADDRESS 43-4.25 N7WA CAL 1C -0
OWNER CONTRACTOR/DESIGNER/ENGINEER
SPAJI S
DEUSM k1"I"ME NrLl, LO -2 !%T ENT K .,ov
P-3 BOX.1 iltl). 79-29-5 RANCHO LA QUINTA DR.,
LA Q)UM,'A C.A. 9225-1 LA QRANI'A CA W2.2,53
(760)77,1-1941 CB110 29%
USE OF PERMIT
SINGLE 'FAMILY-DWELLNG
SM -LOT 10 PLAN W-GIR, F@Uvff W99
AI.Ls OX
.P00,L35% YLA14 0. 16;EE RE.UkXC'�[Oi4 J,'0A,M.CAX1PIX ISSUAWC)3 OV
8 iW121 PLAN '11T E.
ejSTOM C0N3'fR`UCT3.0N Z924AW 91.7
P i
ORCIVP;ATIO I ,K�3.0 5F
0ARACITYCAKPDXT 470.00 SF
E15111all'AlInM C0311T OF CONSIT111,21W rX GIN
PRUFNIff
CO'NMUCTION FlX
101-M-418-000
PLAN CHP -01-K
i 0 1 _000 -43Q -3i 8
NZ1CCJ W41rAL fris
11,014 _141 0-41", -000
111 0. 54)
CLEC T111CAL FT2
101-000-4204N)
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FILUM13fiNG, FIX
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LIEVEJ.,OPER 13YW,,,CT FEE
ART 114 PUBLW PLACE$ - RL -mm 701-000-255-000
I f1
RECEIPT ' I DATE
24,0'417.10
1JESS 1111M."MD FIETS $0.00
TGYfAll, P.E.H.Alff FEM PUENOW $4,14Z.03
DATE FINALED JINSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
— —OU
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap %
F.A.U.
Framing
Oro
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.Q.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
b�
Drywall - Int. Lath
Final3
BLOCKWA
%
L PROVALS
Final
P061 -6 - PAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I
I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
_
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
/
Pool Cover
Sewer Connection
TO
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas) 7 p
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles .00
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
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